Provider Demographics
NPI:1811204936
Name:JACKSON, CRYSTAL I (LGSW-G)
Entity Type:Individual
Prefix:MS
First Name:CRYSTAL
Middle Name:I
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LGSW-G
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:80 INDUSTRIAL PARK DR
Mailing Address - Street 2:SUITE 2B
Mailing Address - City:WALDORF
Mailing Address - State:MD
Mailing Address - Zip Code:20602-2760
Mailing Address - Country:US
Mailing Address - Phone:202-716-4104
Mailing Address - Fax:
Practice Address - Street 1:80 INDUSTRIAL PARK DR
Practice Address - Street 2:SUITE 2B
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20602-2760
Practice Address - Country:US
Practice Address - Phone:202-716-4104
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-10
Last Update Date:2010-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDG13167104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker